Health sector stakeholder reaction to the Queensland budget has been adverse. This in itself is not surprising, given the scale of the workforce cuts. But perhaps the strength of the rhetoric is. AMA Queensland President Dr Alex Markwell described herself as “very disappointed” in Minister Lawrence Springborg. Dietitians Association of Australia CEO Claire Hewat predicted a “tsunami of ill health”. Outgoing head of the Tuberculosis Control Centre, Dr Anastasios Konstantinos, warned of dire consequences.

An adverse reaction from public sector unions, while justified in terms of their own remit, could have been predicted. These voices, however, are not the usual suspects.

Others have written eloquently of the potential impacts on public health. It is indeed puzzling to contemplate how a preventative health strategy could be implemented in the absence of public health staff. It is clear that “front-line services” (now said to be safe from cuts, unlike “front-line workers” such as nurses) will feel the brunt of cuts to programs focusing on infection and disease control, as well as the slashing of preventative initiatives.

The bigger question, in public policy and political terms, is how we have reached this point. And where health in Queensland is going.

It is eminently fair to point out that no one who’s had experience of working in or with Queensland Health would argue that the organisation is a well-oiled machine. Stories of impenetrable silos and grossly inadequate information flows circulate widely. Promising or successful projects implemented in regions — particularly around care of patients with co-morbidities — are not rolled out across the state, and wheels are constantly being reinvented.

An overall focus on system management, on workforce, and on health policy is hard to see, with confusing and tangled lines of accountability in corporate office. The Courier-Mail revealed on the weekend that a crucial memo about the payroll disaster took all of nine months to reach Minister Paul Lucas’ office.

Successive Labor governments played a defensive game following the Jayant Patel scandals and in the face of talkback and press criticism of the availability and quality of care. Though, at the same time, ALP administrations acted to redress the historic underfunding of health care in Queensland.

Labor insiders themselves admit that issues of management and accountability were not front of mind while attempts were made to better fund services at the coalface of patient care and in the public eye.

In the lead-up to this year’s state election, won comprehensively by the Liberal National Party, the Labor Party’s health policy was basically the nuclear option — to abolish Queensland Health and start again from scratch.

Then premier Anna Bligh described Queensland Health as dysfunctional and as having a “sick administrative culture”.

It is unclear how much the thinking in successive KPMG reports commissioned by the Bligh government has factored into the decisions of the Newman government. Lawrence Springborg has not really articulated a vision for health care in this state, and the discourse around Queensland Health has been subsumed into a larger narrative of debt and fiscal fixes. (It’s worth observing that the scale of the fiscal problem as adumbrated in the Costello audit report has been questioned by academic analysts.)

Early in his tenure, Minister Springborg, in announcing that Queensland Association of Healthy Communities would lose much of its state funding, asserted that a model around community advocacy and cohesion should take second place to measures supposed to be more tightly focused on infection prevention.

Hence the notorious “Grim Reaper with a bowling ball” HIV/AIDS campaign had its second coming. Springborg judged the state’s HIV/AIDS prevention strategy harshly on the basis of infection rates, a claim strongly contested by many public health experts. The minister, it would seem, is happy to be judged by results.

Yet, it is hard to believe that he would not have been advised within his own department of the potential results of staff cutbacks, particularly in public health. Certainly he was so advised by stakeholders.

The announcement of additional funding for health directed to weekend services must be the result of a perception that emergency departments and surgery waiting lists are already under strain, and of a public perception of potential health impacts from the cutbacks.

Queensland Nurses Union president Beth Mohle argues that the funding “increases” to health fall behind the growth in demand and in costs. But the political message from the LNP government is clear.

The LNP, Springborg and the governing party’s predecessor the Nationals have long touted local hospital boards as a panacea for health policy.

Critics often felt that such an approach ceded too much power to doctors. That may or may not be warranted, but it’s definitely inconsistent with the very forceful criticism the new government has received from representative medical groups and esteemed and senior clinicians.Certainly there is an arguable case that an appropriate balance needs to be facilitated between centralised policy and oversight and regional and local autonomy and flexibility. A similar set of assumptions was the predicate for the Kevin Rudd health reforms and for Bligh’s deconstruction of Queensland Health.

But the apparent role of the local boards in managing centrally determined cuts to staff numbers and funding and the outsourcing of infection and disease screening and control to local districts suggests that the line has not been appropriately drawn. Meanwhile, the language around “front-line services” seems to have resulted in a gaping hole where public and preventative health should be.

Bligh’s plan notwithstanding, there can never be a blank slate on which health policy can write. Any approach to health system design and management needs to navigate between fundamental population health goals and organisational configuration.

The questions Springborg and Newman need to answer go to whether the changes to Queensland Health have been driven by a political narrative of “Labor debt” and what could almost be characterised as palliative care to keep healthcare rage off the front pages and the radio waves.

In Queensland, we’ve been in that risk-averse space before. It would, too, be reasonable to see the current wave of change as lacking coherency or strategic direction.

The other question the LNP government must address is one it has posed for itself — how its health strategy manifests in patient and population health outcomes. That question cannot be answered on the day after the budget, but it is one whose answer will surely determine the political health of the government itself.

 

*Dr Mark Bahnisch is a Fellow of the Centre for Policy Development and a Postdoctoral Research Fellow in the School of Medicine at The University of Queensland. The views expressed in this post are his own and do not necessarily represent those of associations with which he is associated.